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Full text of "Key Scientific Issues for Research on Violence Occuring Around the Time of Pregnancy"

Key Scientific Issues for Research 
on Violence Occurring Around the 
Time of Pregnancy 

May 8-9, 1997 



»«"**.., 



I ^/ff DEPARTMENT OF HEALTH AND HUMAN SERVICES 




MH07D8124 



rV^OYD^i^ 



Key Scientific Issues for Research on Violence 
Occurring Around the Time of Pregnancy 



By- 
Ruth Petersen, MD, MPH 
Linda E. Saltzman, PhD 
Mary Goodwin, MA, MP A 
Alison Spitz, MS, MPH 



Prepared for the National Center for Chronic Disease Prevention and 
Health Promotion, and the National Center for Injuiy Prevention and 
Control, Centers for Disease Control and Prevention, Atlanta, Georgia, 
April, 1998 



Reprint requests to Ms. Spitz, Division of Reproductive Health, K-35, Centers for Disease Control and 
Prevention, 4770 Buford Hwy, Atlanta, GA 30341-3724. Telephone: (770) 488-5258; fax: (770) 488-5965; 
e-mail: ams2@cdc.gov. 



Table of Contents 

Introduction 1 

Objectives 3 

Objective 1 5 

Define violence occurring around the time of pregnancy; define 
violence during pregnancy. 

Objective 2 7 

Agree on terminology related to the study of violence occurring around 
the time of pregnancy. 

Types of Violence and Abuse 7 

Terms Regarding Relationships 8 

Miscellaneous Terms 9 

Objective 3 11 

Establish guidelines for use in future research regarding periods of 
observation and milestones to be used in the collection of data in the 
study of violence occurring around the time of pregnancy. 

Periods of Observation 12 

Examples of Milestones 13 

Objective 4 15 

Establish a list of clear and consistent research questions to guide 
future research. 

Objective 5 19 

Establish a set of categories to guide the selection of variables for 
investigating violence occurring around the time of pregnancy. 

Topic Areas 19 

Acknowledgments and Work Group 23 

References 25 



Introduction 



Violence against women is increasingly recognized to be an important clinical and public 
health issue. In the United States an estimated 1.8 million women (3% of women overall) 
are severely assaulted by their male partners each year. Estimates of the prevalence of 
violence during pregnancy developed from clinic-based studies range from 0.9% to 
20.1%, but the bulk of studies have found a prevalence of 3.9% to 8.3%.' Applying these 
percentages to the 3.9 million U.S. women who delivered live-born infants in 1995 yields 
the conclusion that 152,000 to 324,000 women experienced violence during their 
pregnancies. 2 Thus, violence may be more common for pregnant women than 
preeclampsia, gestational diabetes, or placenta previa. 1 ' 3 

In recognition of the increasing awareness of violence during pregnancy and the emerging 
research in this area, the Centers for Disease Control and Prevention (CDC) has produced 
three systematic reviews of the literature on this topic, focusing specifically on prevalence, 
measurement, and outcomes. 1 ,4,5 These reviews show the difficulty of drawing conclusions 
from the published studies and then generalizing the results, because studies differ in 
populations sampled, methods, and approaches to measuring violence. Having 
standardized methods of estimating the prevalence of violence against pregnant women; of 
studying the association between the experience of violence and pregnancy; and of 
evaluating risk factors, protective factors, and outcomes of violence occurring around the 
time of pregnancy are all important for developing, implementing, and evaluating 
prevention and intervention strategies. 

The need for greater standardization of research in order to facilitate comparability among 
studies prompted the CDC to bring together in May 1 997 a number of investigators who 
had published research on pregnancy-related violence, as well as others with public health 
expertise in violence prevention. This report summarizes the collective recommendations 
resulting from that meeting, which was held in Atlanta. Sponsors included the Division of 
Reproductive Health, National Center for Chronic Disease Prevention and Health 
Promotion (DRH/NCCDPHP); the Division of Violence Prevention, National Center for 
Injury Prevention and Control (DVP/NCIPC); and the Office of Women's Health (OWH). 
The Office of Population Affairs of the Public Health Service also participated. 

This report has been specifically designed to guide research investigating violence 
occurring around the time of pregnancy. Pregnancy is a unique time for intervention and 
prevention efforts because many women may have increased or initial contact with health 
care providers. Other issues related to pregnancy, such as changes in a woman's self 
esteem, changes in relationships with her partner, concerns for the future, and feeling 
responsible for her developing child may offer increased possibilities for intervening in a 
cycle of violence. 

To date, specific investigation of violence around the time of pregnancy has been so 

1 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



limited that we do not even know whether violence during pregnancy is precipitated by 
issues related to pregnancy, whether violence increases during pregnancy, or whether, in 
general, the experience of violence increases the risk of poor pregnancy outcome. 6 
Research will need to continue to identify issues that are causal for violence occurring 
around the time of pregnancy, including such factors as substance abuse, intendedness of 
pregnancy, and jealousy. 7 " 10 Additionally, many risk and protective factors still need to be 
investigated regarding violence occurring around the time of pregnancy to improve the 
targeting of interventions and prevention strategies. (The term "risk factor" is used in this 
report to indicate items associated with violence around the time of pregnancy; they may 
be causative or not.) Modifying these risk factors through interventions might limit the 
occurrence of violence occurring around the time of pregnancy. 11 The term "protective 
factor" is used to indicate items that are associated with a decreased risk for violence 
around the time of pregnancy. 

Although future research on violence related to any issue or occurring at any point in a 
woman's life is important, this report specifically focuses on violence occurring around the 
time of pregnancy. Violence related to a variety of other issues also merits intensified 
research efforts. 

Violence occurring around the time of pregnancy can occur between victims and 
perpetrators who are known to each other or who are strangers. This report focuses on 
perpetrator-victim relationships between people who know each other, including past or 
current intimate partners, family members, and acquaintances/friends, because a majority 
of perpetrators are known to their victims 12 and because intervention strategies vary 
according to the relationship of perpetrator to victim. 

Future research on violence occurring around the time of pregnancy will be enhanced by 
drawing on already developed theories. An array of theories, from a variety of disciplines 
may be applicable. 13 " 19 For example, social learning theories may be important in 
understanding the perpetrator's behavior or use of violence. 15 Similarly, the theories of 
health protective behavior, or adaptations of these theories, may help researchers 
understand a woman's efforts (or lack of efforts) to protect herself, her fetus, or her child 
from violence during or after pregnancy. 16 " 19 In addition to theories that can be applied at 
the level of the individual (microlevel), there are theories that may be useful in addressing 
the influence of macrolevel or contextual factors. 13 ' 20 " 21 Available theories can also be used 
to select variables researchers will need to investigate their hypotheses. Future research 
should use theories that address both microlevel and macrolevel data for both the victims 
and the perpetrators. 

This report supports the conduct of research that is, among other things, ethical, legal, and 
safe. Research must avoid jeopardizing or compromising the interests of women exposed 
to or at risk of violence. Research hypotheses, data collection efforts, and the content of 
questionnaires must avoid blaming the victim or violating a woman's privacy. Researchers 
will have to assess the impact of data collection on the safety of the individuals involved in 
the study. Research protocols will need to allow for the termination of data collection as 

2 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



well as access to interventions when those involved in the study are endangered by their 
participation or otherwise need protective action. In addition, child abuse and neglect or 
statutory rape may be discovered in the research process; study protocols will have to 
incorporate contact with child welfare and/or law enforcement agencies. 22 Complete 
discussion of the evolving legal, ethical, and safety concerns raised by future research is 
beyond the scope of this report. Several researchers and organizations have developed 
guidelines that begin addressing these issues, but they are not specifically related to 
violence occurring around the time of pregnancy. 22 " 26 



Objectives 



The overall goal of the May 1 997 meeting was to obtain the input of researchers and 
victim-advocates on key scientific issues related to future research involving violence 
around the time of pregnancy. The specific objectives that are summarized in this report 
include the following: 

1. Define violence occurring around the time of pregnancy; define violence during 
pregnancy. 

2. Agree on terminology related to the study of violence occurring around the time of 
pregnancy. 

3. Establish guidelines for use in future research regarding periods of observation and 
milestones to be used in the collection of data in the study of violence occurring 
around the time of pregnancy. 

4. Establish a list of clear and consistent research questions to guide future research. 

5. Establish a set of categories to guide the selection of variables for investigating 
violence occurring around the time of pregnancy. 

Discussion of these five objectives has been an important first step toward greater 
standardization of future research. However, there are additional issues of great 
importance in the study of violence occurring around the time of pregnancy. Ideas and 
actions suggested at the meeting for future discussion and research included the following: 

1. Develop and refine measurement instruments and specific measures; 27 " 29 

2. Develop recommendations and specific strategies for the use of quantitative and 
qualitative research designs; 30 " 32 

3. Develop strategies for research designs that examine pregnancy as a risk factor for 
violence by comparing pregnant and nonpregnant women; 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



4. Determine ways to address violence experienced by women as a chronic and 
continuous process (a process some researchers refer to as battering). Future work in 
this area would stress the nonphysical effects the victim can experience such as 
feelings of entrapment or loss of control 33 " 36 ; and 

5. Further delineate the ethical, legal and safety issues related to the study of violence 
occurring around the time of pregnancy. 

The key issues identified in this report will be important in planning, designing and 
implementing research investigating violence occurring around the time of pregnancy, but 
this constitutes only an initial approach to standardizing research in this area. The 
examples are meant to provide ideas upon which researchers can build. 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Objective 1 



Define violence occurring around the time of pregnancy; 
define violence during pregnancy. 

A lack of clearly defined time periods of exposure in individual studies addressing violence 
around the time of pregnancy has led to an inability of these studies to accurately measure 
the association between violence and pregnancy. Furthermore, inconsistency among 
studies in defining time periods of exposure has led to an inability to compare study 
findings. To address these issues, the following definitions of "violence occurring around 
the time of pregnancy" and "violence during pregnancy" are suggested: 

Term Definition 

Violence occurring Physical, sexual, or psychological/emotional violence, or threats of 
around the time of physical or sexual violence that are inflicted on a woman during the 
Dreenancv prepregnancy, pregnancy, or postpregnancy periods or some 

combination of these periods (see Objective 3 for definitions of time 

periods). 

Violence during Physical, sexual, or psychological/emotional violence, or threats of 

pregnancy physical or sexual violence that are inflicted on a pregnant woman. 

Violence during pregnancy is a subset of violence occurring around the 

time of pregnancy. 



Key Scientific issues for Research on Violence Occurring Around the Time of Pregnancy 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Objective 2 



Agree on terminology related to the study of violence 
occurring around the time of pregnancy. 

Consistent terminology is not used in the study of violence occurring around the time of 
pregnancy. To address this issue, several terms 3 are proposed on the following pages for 
future use: terms were chosen for their applicability to violence around the time of 
pregnancy, their inconsistent use to date in the literature, and the importance they will play 
later in this report in the discussion of research topics and variables. These terms are 
presented as a reference so that, in future discussions and research, they may be used as 
consistently as possible by different researchers. Some terms are described in only a 
general sense so that researchers can further define them to make them applicable to their 
investigation. 



Subcategory 
Physical violence 3 



Sexual violence 3 



Types of Violence and Abuse 

Description 

Intentional use of physical force with potential for causing death, injury, or harm. 
Physical violence includes, but is not limited to scratching, pushing, shoving, 
throwing, grabbing, biting, choking, shaking, poking, hair pulling, slapping, 
punching, hitting, burning, and use of restraints or one's body, size, or strength 
against another person. Physical violence includes the use of a weapon against a 
person. 

Use of physical force to compel a person to engage in a sexual act (see definition 
on page 9) against her will, whether or not the act is completed. 

An attempted or completed sexual act (see definition on page 9) involving a 
person who is unable to understand the nature or condition of the act, decline 
participation, or to communicate unwillingness to engage in the sexual act, e.g. 
due to illness, disability, the influence of alcohol or other drugs, or intimidation 
or pressure. 

Abusive sexual contact (see definition on page 9). 



a These terms evolved from a meeting convened by DVP/NCIPC in 1 996 at CDC. At this meeting, a panel of experts 
established guidelines for intimate partner violence surveillance. Terms that emerged from this conference are being pilot 
tested in three states. For more information on this meeting and these terms contact: Family and Intimate Violence 
Prevention Team, K-60, Centers for Disease Control and Prevention, 4770 Buford Hwy, Atlanta, GA 30341-3724; 
telephone: (770) 488-4410; fax: (770) 488-4349. 

7 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Threat of physical 
or sexual violence 3 



Psychological/ 
emotional abuse 3 



An expression of intent to cause death, injury, or physical harm through the use 
of words, gestures, or the use of a weapon; or to compel a person to engage in 
sexual acts or abusive sexual contact when the person is either unwilling or 
unable to give consent. 

Trauma to the victim caused by acts, or threats of acts, such as humiliating the 
victim, controlling what the victim can and cannot do, withholding information 
from the victim, or getting annoyed if the victim disagrees. This may include 
coercive tactics. 



Psychological/ For psychological or emotional abuse (see definition above) to be considered a 

emotional abuse as a type of violence, there must also have been prior physical or sexual violence (or a 
type of violence 3 threat of such violence). 



Term 
Victim 3 
Perpetrator 3 

Intimate partner 3 



Violent intimate 
partner 3 

Acquaintance/ friend 

Family member 

Stranger 

Biological father of baby 



Terms Regarding Relationships 

Description 

Person who is target of violence or abuse. 

Person who inflicts violence or abuse, or causes these to be inflicted, on the 
victim. 

Includes current and former spouses (legal and common law), non-marital 
partners (boyfriend, girlfriend, same-sex partner, dating partner). Intimate 
partners may or may not be cohabitating; the relationship need not involve 
sexual activities. 

Intimate partner (see definition above) who has perpetrated violence on his or 
her partner. 

Known individual who is not an intimate partner. 

Parent (including step-parents), children, siblings, and other relatives, 
including in-laws. 

Person not known. 

Person by whom a woman is pregnant. 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Miscellaneous Terms 



Term 

Sexual act 3 



Abusive sexual contact 3 



Violent episode 3 



Most recent violent 
episode 3 



Frequency 

Severity 

Chronicity 

Infant 

Fetus 



Adverse pregnancy 
outcomes 



Description 

Contact between the penis and the vulva, or the penis and the anus, involving 
penetration however slight; contact between the mouth and penis, vulva, or 
anus; or penetration of the anal or genital opening of another person by a 
hand, finger, or other object. 

Intentional touching directly or through the clothing of the genitalia, anus, 
groin, breast, inner thigh, or buttocks of any person against her will, or of any 
person who is unable to understand the nature or condition of the act, decline 
participation, or to communicate unwillingness to be touched. 

An act or series of acts of violence. May involve multiple types of violence 
(e.g. physical, sexual, threat of physical or sexual violence, 
psychological/emotional) or may involve repetition of violence over a period 
of minutes, hours, or days. 

For victims who have or have had more than one violent intimate partner, the 
most recent violent episode may have been perpetrated by someone other 
than the victim's current partner. For example, if a woman has been 
victimized by her husband and her former husband, questions about the most 
recent violent episode would refer to the episode involving whichever partner 
victimized her most recently. 

Number of episodes of any given kind in unit of time. 

Level of intensity, such as degree of injury or level of victim's fear. 

The state of continuing a long time or recurring frequently. 

Child(ren) under age 1 year delivered from victim. 

Product of conception from 8 weeks after fertilization to delivery or 
termination. 37 

Physical, mental, fetal, or maternal outcomes subsequent to violence. 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Objective 3 



Establish guidelines for use in future research regarding 
periods of observation and milestones to be used in the 
collection of data in the study of violence occurring around 
the time of pregnancy. 

Time periods of observation, periods of violence ascertained by studies, and the timing of 
data collection vary among researchers investigating violence around the time of 
pregnancy. 1 ' 4 Inconsistencies have led to the inability to draw conclusions about the 
findings across studies, to determine whether violence is related to pregnancy, and to 
reach conclusions about change in levels of violence at different periods of observation. 1 ' 4 
Guidelines for periods of observation and milestones to be used in data collection will help 
limit inconsistencies in future research. 



Periods of observation 

The suggested time periods of observation for the study of violence occurring around the 
time of pregnancy, illustrated in Table 3-1, include the periods of pregnancy, 
prepregnancy, and postpregnancy. Consistent with the concept of the preconception 
period, the prepregnancy period includes 1 year prior to pregnancy. The pregnancy period 
is considered to be from the time of the last menstrual period until delivery or termination. 
The postpregnancy period is separated into two categories: (1) up to 6 weeks after 
delivery or termination and (2) 6 weeks to 1 year after delivery or termination. The 
rationale for having two categories was to distinguish the issues and events that may occur 
in the immediate postpregnancy period, which is characterized by rapid physical and 
mental changes, from those that occur later in the postpregnancy period. The 6-week 
demarcation is also useful because many women schedule a health care visit at this time. 

The suggested periods of observation can be further subdivided based on the research 
resources available. For example, the period of pregnancy could be divided by trimester or 
at the 20-week point. The immediate postpregnancy period could be subdivided into a 
postpregnancy period of 1 week and a postpregnancy period of more than 1 and up to 6 
weeks. 

Future research should capture and distinctly record events occurring during the periods 
of pregnancy, prepregnancy, and postpregnancy. For example, if researchers ask women 
during postpregnancy about prepregnancy and pregnancy, they should ask separately 
about each specific period. Researchers should report findings from the particular time 
periods for which women are screened and not generalize about portions of time periods 
that were not assessed. The specific periods of observation from which data will need to 

1 1 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



be collected will depend on the research question being asked. These periods may overlap 
between consecutive pregnancies if a woman becomes pregnant again soon after a delivery 
or termination. 

Table 3-1: Periods of observation regarding violence exposure in the 
study of violence occurring around the time of pregnancy 



Past 


Prepregnancy 


Pregnancy 


Postpregnancy 


Long-term 


Childhood 


1 year prior to 
pregnancy 


Time of last 
menstrual period 
until delivery or 

termination 


Up to 6 weeks 

after delivery or 

termination 


More than 1 year 

after delivery or 

termination 


Adolescence 


Adulthood 


6 weeks to 1 year 

after delivery or 

termination 



Milestones 

Researchers may want to ask a woman to recall important events, or milestones, in her life 
to improve her recall and reported timing of events. Each period of observation will have 
its own specific milestones that may be useful as anchors when data are collected. 
Researchers should use this list because it may help women recall and place the timing of a 
violent episode, whether or not it precipitated episodes of violence or is related to 
violence. Examples of milestones are listed in Table 3-2. 

Concerns related to data collection will differ by whether data are collected by personal 
interviews, self-administered questionnaires, or through focus groups. Guidelines will 
depend on the training and characteristics of the persons administering these various data 
collection methods. A more general discussion of methods used to collect data is beyond 
the scope of this report. 



12 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Table 3-2: Examples of Milestones by Periods of Observation 

Prepregnancy 



Pregnancy 



Postpregnancy 



< Discussion with partner and/or perpetrator regarding pregnancy 

< Intentional cessation of contraception use 

< First missed menstrual period 

< Suspicion of pregnancy 

< Confirmation of pregnancy 

< Disclosure of pregnancy to partner or perpetrator 

< First prenatal visit 

< Hearing heart tones 

< Quickening 

< First ultrasound (including confirmation of congenital anomalies) 

< Confirmation of gender of fetus 

< Change in health risk behavior (e.g., cessation of smoking or drinking) 

< Point at which pregnancy changes from normal to high risk (including 
compliance with necessary regimens such as bed rest) 

< Postpartum visit to health care provider 

< First menstrual period 

< Resumption of sexual intercourse 

< Re-initiation of contraception 

< Return to work 



13 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



1 4 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Objective 4 



Establish a list of clear and consistent research questions to 
guide future research. 

Examples of research questions are offered here to begin to establish a set of clear and 
consistent questions to be used in the investigation of violence occurring around the time 
of pregnancy. Having this set of questions should improve the comparison of study results. 

Prevalence 

Example questions: 

< How many women (and what proportion of women) have experienced violence in the 
different periods of observation around the time of pregnancy? 

< What proportion of men have perpetrated violence on women in the different periods 
of observation around the time of pregnancy? 

Characteristics of Violence 

Example questions: 

< What is the severity of violence during individual observation periods (prepregnancy, 
pregnancy, postpregnancy)? 

< How does the severity of violence change during individual observation periods 
(prepregnancy, pregnancy, postpregnancy)? 

< Does the type of violence differ by observation period (prepregnancy, pregnancy, 
postpregnancy)? 

< Does the type of violence change across individual observation periods (prepregnancy, 
pregnancy, postpregnancy)? 

< How does the type and severity of violence around the time of pregnancy differ by 
selected characteristics of women (e.g., age, socioeconomic status, urban/rural 
residence)? 

Causality 

Example questions: 

< Is violence a consequence of pregnancy? 

< Is pregnancy a consequence of violence? 

< Are there specific issues related to pregnancy, such as unintendedness or jealousy 

1 5 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



regarding the pregnancy, that are causes of violence? 
Risk or Protective Factors for Victimization 

Example questions: 

< What are the contexts in which violence occurs around the time of pregnancy? 

< What are the risk factors for violence around the time of pregnancy? 

< How do the risk factors for violence around the time of pregnancy differ by selected 
characteristics of women (e.g., age, socioeconomic status, urban/rural residence)? 

< What are the most common and important individual and contextual protective factors 
that mitigate the severity or frequency of violence around the time of pregnancy for 
women at risk? 

< What factors (individual and contextual) prompt women experiencing violence around 
the time of pregnancy to seek help? 

Risk or Protective Factors for Perpetration 

Example questions: 

< What characteristics of perpetrators are associated with their being violent to women 
around the time of pregnancy? 

< What are the most common and important protective factors (individual and 
contextual) that prevent or modify the violent actions of the perpetrator? 

Outcome 

Example questions: 

< What are the adverse outcomes (e.g., maternal, fetal, physiological, psychological, 
social, economic) of violence during pregnancy? 

< What are the differences in adverse pregnancy outcomes between women who 
experience violence and women who do not experience violence? 

< How many women (and what proportion of women) experience adverse outcomes of 
violence during pregnancy? 

< For a particular adverse pregnancy outcome (e.g., low birthweight), what proportion 
of the outcome is associated with violence during pregnancy? 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Screening 

Example question: 

< What are effective screening mechanisms and optimal times for identifying violence 
occurring to women in the prepregnancy, pregnancy, and postpregnancy periods? 

Prevention and Intervention 

Example questions: 

< What protective factors (individual and contextual) prevent women from experiencing 
violence around the time of pregnancy? 

< What are effective violence prevention programs for women who are in the 
prepregnancy, pregnancy, and postpregnancy periods? 

< What are effective intervention programs for women who are being victimized, or who 
are at risk of victimization, in the prepregnancy, pregnancy, and postpregnancy 
periods? 

< What characteristics of the perpetrator would be amenable to interventions for 
preventing violence to women around the time of pregnancy? 

< What are effective training programs to encourage health care providers to ask and 
identify women who are at risk for violence during the prepregnancy, pregnancy, and 
postpregnancy periods? 



17 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



I ** Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Objective 5 



Establish a set of categories to guide the selection of 
variables for investigating violence occurring around the 
time of pregnancy. 

This objective provides variables, listed by categories, that may be used in future 
investigation of violence occurring around the time of pregnancy. The use of these 
variables will depend on which research question is being investigated. Researchers 
involved in this area will need to make decisions regarding how to measure the selected 
variables and what measurement tools or scales to use (operationalization). 

Topic Areas 



Categories of Variables 



Time period of 
occurrence of violence 

Type of violence 



Characteristics of 
violence, most recent or 
past episodes 



Subcategories of Variables 
Description of index episode of violence 

Past, prepregnancy, pregnancy, postpregnancy (see Table 3-1). 

Physical, sexual, threat of physical or sexual violence, 
psychological/emotional * 

Frequency and severity of violence* 



Demographic 
characteristics of victim 



Demographic 
characteristics of 
perpetrator(s) 



Demographics 

Age, race and ethnic group, marital status and co-habitation 
status, socioeconomic status, occupation/employment, 
education, location of birth (U.S. versus foreign-born) 

Age, race and ethnic group, marital status and co-habitation 
status, socioeconomic status, sex, occupation/employment, 
education, location of birth (U.S. versus foreign-born) 



19 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



i^naractenstics oi reiationsnrp between victim and perpetrator(S) 



Type 

Characteristics of 
relationship 

Relationship history 



Intimate partner, family member, acquaintance/friend* 

Relationship satisfaction, conflict-resolution style, control of 
decision-making (such as with contraception), power in 
relationship 

Time that perpetrator and victim have known each other, time 
that victim and perpetrator have been intimate partners, time 
since first episode of violence with perpetrator, periods of 
cohabitation and separation, whether relationship continued 
subsequent to violence, whether perpetrator is also the father of 
the baby (or believes he is or is not) 

Characteristics of victim and perpetrator 

.■■ft: *■/■ : : » ■■-■ 



Characteristics of victim 



Characteristics of 
perpetrator 



Awareness of pregnancy at time of violence, response to 
pregnancy, health status, reproductive history, mental health 
status (stress, depression, suicidal gestures/attempts, anxiety, 
post-traumatic stress disorder), substance abuse, perceived 
access to services, religion, disability status 

Awareness of pregnancy at time of violence, response to 
pregnancy, number of perpetrators, mental health status (stress, 
depression, suicidal gestures/attempts, anxiety, post-traumatic 
stress disorder), substance abuse, religion, disability status 



Characteristics of index pregnancy to consider as risk factors and con founders 

See current literature for suggestions. 38 



Intendedness of 
pregnancy 

Health care utilization, 
other than routine 
prenatal care, during 
pregnancy 



Site of utilization, reason for utilization 



Adequacy of prenatal care See current literature for suggestions. 



39-41 



Risk factors for poor 
pregnancy outcomes 

Health behavior changes 
recommended by health 
care provider 



Smoking, alcohol use, illicit drug use, presence of sexually 
transmitted disease, preexisting conditions of pregnancy, clinical 
conditions 

Bed rest, abstinence from intercourse, smoking and alcohol 
cessation, cessation of working 



20 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Outcome of index episode of violence 



Physical injury to victim 
or fetus 



Type, severity, location on body or site of injury 



Physical health outcomes Type, severity 
to victim or fetus 

Pregnancy as an outcome Occurrence of pregnancy 
of violence 



Adverse pregnancy 
outcomes* 

Psychological outcome 

Health care received 

Utilization of other 
community services 



Type, severity 

Type, severity 

Site of utilization, amount of utilization, reason for visit 

Site of utilization, amount of utilization, reason for visit 



Characteristics of living 
environment 

Family norms 



Affiliation between the 
family and others 



Community norms 



Economic characteristics 
of community 

Characteristics of the 
community 

Social oppression 



Living environment 

Family size, including other children, physical living 
arrangements 

Norms regarding attitudes toward pregnancy, attitudes and 
history toward violence and violence against women, decision- 
making 

Degree and source of social support (including extended family 
and other networks), amount of isolation, connection with 
community 



Community contexts 

Norms regarding pregnancy, pregnancy disclosure, violence, 
violence against women (including attitude of law enforcement 
agencies), masculinity, immigrants, culture and ethnicity 

Employment opportunities, distribution of resources and 
services, home ownership 

Geography, density, degree of social unrest, presence of 
volunteer organizations, availability of transportation, 
characteristics of health care system 

Degree of racism, sexism, economic discrimination 



21 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Public policy context 



Justice system Local laws, legal protection, biases of system 

Availability of services Access to shelters, mental health counseling, drug and alcohol 

treatment, subsidized housing, advocacy, services to protect 
women and other assistance 

Public policy changes Welfare reform, funding, lack of support if mother is substance 

abuser 



Described in Objective 2. 



22 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



Acknowledgments 

This report was made possible through support from the National Center for Chronic 
Disease Prevention and Health Promotion* (NCCDPHP); the National Center for Injury 
Prevention and Control** (NCIPC), and the Office of Women's Health (OWH). The 
Office of Population Affairs of the Public Health Service participated in the meeting. 



Meeting Coordinators 

Mary Goodwin* 
Ruth Petersen 
Linda E. Saltzman** 
Alison Spitz* 

Meeting Facilitator 

Joe Sniezek** 

Meeting Writer/Editor 

Deborah Kowal 

The working group for this meeting 
included: 

Panel Members 

Terri Ballard 
Abbey B. Berenson 
Jacquelyn Campbell 
Julie Gazmararian 
Paula J. Adams Hillard 
Sandra L. Martin 
Judith McFarlane 
Patricia J. O'Campo 
Barbara Parker 
Ruth Petersen 
Linda E. Saltzman 
Carolyn M. Sampselle 
Donna E. Stewart 
Joan Webster 



External Reviewers, continued 

Tracey Rattray 
Kim Riordan 
Jennifer Robertson 
Ama R. Saran 
Paige Hall Smith 

CDC, Division of Reproductive 
Health, NCCDPHP 

Patty Dietz 
Mary Goodwin 
Lisa Koonin 
Jackie Rosenthal 
Diane Rowley 
Alison Spitz 
E. Thomas Starcher II 
Dora Warren 
Lynne Wilcox 

CDC, Division of Violence Prevention, 
NCIPC 

Janet Fanslow 
Denise Johnson 
Pam McMahon 
Linda E. Saltzman 
Lynn Short 

CDC, Office of Women's Health 

Michael Brown 
Wanda Jones 



External Reviewers 

Diane K. Bohn 
Nancy Durborow 
Deborah Horan 
Eli Newberger 



Office of Population Affairs 

Thomas Kring 



23 



Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



24 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



References 

1 . Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. 
Prevalence of violence against pregnant women: A review of the literature. JAMA 
1996;275:1915-1920. 

2. Ventura SJ, Martin JA, Curtin SC, Mathews TJ. Advance report of final natality 
statistics, 1995. Monthly Vital Statistics Report 1997;45S:l-84. 

3. Cunningham FG, MacDonald PD, Gant NF, et al. Williams Obstetrics. 19th ed. East 
Norwalk, CT: Appleton & Lange; 1993. 

4. Ballard TJ, Saltzman LE, Gazmararian JA, Spitz AM, Lazorick S, Marks JS. Violence 
during pregnancy: Measurement issues. Am J Public Health 1998;88:274-276. 

5. Petersen R, Gazmararian JA,'Spitz AM, Rowley DL, Goodwin MM, Saltzman LE, 
Marks JS. Violence and adverse pregnancy outcomes: A review of the literature and 
directions for future research. Am J Prev Med 1997;13:366-73. 

6. Newberger EH, Lieberman ES, McCormick MC, Yllo K, Gary LT, Schechter S. 
Physical and sexual abuse of women and adverse birth outcome. In: Fuchs AR, Fuchs F, 
Stubblefield PG, eds. Preterm Birth: Causes, Prevention and Management. 2nd ed. New 
York: McGraw-Hill; 1993:89-95. 

7. Gelles RJ. Violence and pregnancy: A note on the extent of the problem and needed 
services. Fam Coordinator 1975;24:81-6. 

8. Campbell JC, Oliver C, Bullock L. Why battering during pregnancy? AWHONN's Clin 
Issues Perinat Womens Health Nurs 1993;4:343-9. 

9. Gazmararian JA, Adams MM, Saltzman LE, Johnson CH, Bruce FC, Marks JS, 
Zahniser SC, and the PRAMS Working Group. The relationship between pregnancy 
intendedness and physical violence in mothers of newborns. Obstet Gynecol 1995; 
85:1031-8. 

10. Berenson AB, San Miguel W, Wilkinson GS. Violence and its relationship to 
substance use in adolescent pregnancy. J Adolesc Health 1992;13:470-4. 

1 1 . Last JM, ed. A Dictionary of Epidemiology. New York: Oxford University Press, 
1988:1115-6. 

12. Bachman R, Saltzman LE. Violence against women: Estimates from the redesigned 
survey. National Crime Victimization Survey, Bureau of Justice Statistics. August 1995. 

13. O'Campo P, Gielen AC, Faden RR, Xue X, Kass N, Wang MC. Violence by male 

25 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



partners against women during the childbearing year: A contextual analysis. Am J Public 
Health 1995;85: 1092-7. 

14. Campbell JC. Wife -battering: Cultural contexts versus western social sciences. In: 
Counts DA, Brown JK, Campbell JC, eds. Sanctions and Sanctuary: Cultural Perspectives 
on the Beating of Wives. Boulder, CO: Westview Press; 1992. 

15. Aiken LR. Personality: Theories, Research, and Applications. Englewood Cliffs, NJ: 
Prentice Hall; 1993:213-5. 

1 6. Weinstein ND. Testing four competing theories of health-protective behavior. Health 
Psychol 1993;12:324-33. 

17. Rotter JB. Generalized expectancies for internal versus external control of 
reinforcement. Psychol Monogr 1966:80; 1-28. 

18. Stretcher VJ, DeVellis BM, Becker MH, Rosenstock IM. The role of self-efficacy in 
achieving health behavior change. Health Educ Q 1986;13:73-91. 

19. Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr 

1974;2:328. 

20. Crane J. The epidemic theory of ghettos and neighborhood effects on dropping out 
and teenage childbearing. Am J Sociology 1991;96:1226-59. 

21. Sampson RJ. Linking the micro- and macrolevel dimensions of community social 
organization. Social Forces 1991;70:43-64. 

22. Hill A. Screening and Reporting Domestic Violence Among Adolescents. Violence 
Prevention Project. Contra Costa's Community Wellness & Prevention Program. Contra 
Costa County (California) Health Services Department, Public Health Department. 
Telephone: 510-313-6827. 

23. Liss M, Solomon SD. Ethical considerations in violence-related research. Unpublished 
material. National Institutes of Health. Bethesda, MD. 

24. Texas Council on Family Violence. Research policy. Unpublished material. 

25. Parker B, Ulrich Y, Nursing Research Consortium on Violence and Abuse. A protocol 
of safety: Research on abuse of women. Nurs Res 1990; 39:248-50. 

26. Cain JM. The ethical and medical consequences of violence against women. Int J 
Gynaecol and Obstet 1996;54:97-100. 

27. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott 

26 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



JT. Accuracy of 3 brief screening questions for detecting partner violence in the 
emergency department. JAMA 1997;277:1357-61. 

28. Campbell DW, Campbell J, King C, Parker B, Ryan J. The reliability and factor 
structure of the Index of Spouse Abuse with African- American women. Violence Vict 
1994;9:259-74. 

29. Norton LB, Peipert JF, Zierler S, Lima B, Hume L. Battering in pregnancy: An 
assessment of two screening methods. Obstet Gynecol 1995;85:321-5. 

30. Ratcliffe JW, Gonzalez -del-Valle A. Rigor in health-related research: Toward an 
expanded conceptualization. Int J Health Serv 1988;18:361-92. 

3 1 . Bauer MC, Wright AL. Integrating qualitative and quantitative methods to model 
infant feeding behavior among Navajo mothers. Hum Organization 1996;55:183-92. 

32. Steckler A, McLeroy KR, Goodman RM, Bird ST, McCormick L. Toward integrating 
qualitative and quantitative methods: An introduction. Health Educ Q 1992;19:1-8. 

33. Smith PH, Earp JA, DeVellis R. Measuring battering: Development of the Women's 
Experience with Battering (WEB) scale. Womens Health: Res Gender Behav Policy 
1995;1:273-88. 

34. Campbell JC, Humphreys JC. Nursing Care of Survivors of Family Violence. St. 
Louis, MO, Mosby. 1993. 

35. Smith PH, Tessaro I, Earp JL. Women's experiences with battering: A 
conceptualization from qualitative research. Womens Health Issues 1995;5:173-82. 

36. Stark E, Flitcraft A. Spouse abuse. In: Rosenberg ML, Fenley MA, eds. Violence in 
America. New York: Oxford University Press; 1991:123-57. 

37. Holtzman GB, Rinehart RD, eds. Planning for pregnancy, birth, and beyond. 2nd ed. 
American College of Obstetricians and Gynecologists. Washington DC; 1995: 25. 

38. Brown SS, Eisenberg L, eds. The Best Intentions: Unintended Pregnancy and the 
Weil-Being of Children and Family. Committee on Unintended Pregnancy, Institute of 
Medicine. Washington DC: National Academy Press; 1995. 

39. Alexander GR, Kotelchuck M. Quantifying the adequacy of prenatal care: A 
comparison of indices. Public Health Rep 1996;1 1 1:408-18. 

40. Kotelchuck M. An evaluation of the Kessner adequacy of prenatal care index and a 
proposed adequacy of prenatal care utilization index. Am J Public Health 1994;84:1414- 
20. 

27 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy 



41. Dietz PM, Gazmararian J A, Goodwin MM, Bruce FC, Johnson CH, Rochat RW, and 
PRAMS Working Group. Delayed entry to prenatal care: Impact of physical violence. 
Obstet Gynecol 1997;90:221-4. 



28 Key Scientific Issues for Research on Violence Occurring Around the Time of Pregnancy